SHS Rationale

“Promoting Adolescent Health through School-Based HIV Prevention”

OMB #0920-new

Attachment 9b SHS Rationale

Key Sexual Health Services (SHS)

Rationale:

In 2010, young people aged 13–24 accounted for 26% of all new HIV infections in the United States,¹ and nearly half of the 19 million new sexually transmitted diseases (STD) reported each year are among young people ages 15–24.² Roughly 25% of women aged 14–19 have had a human papillomavirus (HPV) infection, the most common STD, which is linked to negative health outcomes including genital warts and cervical, vaginal, vulvar, anal, penile, and oral cancers. ³ Many adolescents engage in sexual risk behaviors that can result in such unintended health outcomes. For example, among U.S. high school students surveyed in 2011, almost half reported ever having had sex. Of those sexually active in the previous 3 months, about a third did not use a condom.⁴

Preventive services provided by medical providers can have a significant impact on reducing risk behavior and the testing and treatment of infections to help stop the spread of STD and HIV. Several official and national guidelines for adolescent preventive care specifically include recommendations for the provision of sexual and reproductive health services for adolescents to attend to these health problems and to provide preventive services^5-8 including HIV testing beginning at age 13 in areas more affected by HIV; gonorrhea and Chlamydia screening of sexually active females ages 25 and younger, and Human Papilloma Virus vaccination beginning at ages 11-12. Guidelines for HIV and STD testing emphasize adolescents because of the increased burden among this age group and the importance of establishing a pattern of routine testing early in life.^9-11 CDC guidelines recommend routine vaccination of young adolescents^12-13 against HPV, largely because first infection is often acquired shortly following sexual initiation¹⁴ and because people have better immune response to HPV vaccine at younger ages.¹⁵

Schools in the United States have a critical role to play in facilitating delivery of such needed preventive services for adolescents; schools have direct daily contact with more than 30 million adolescent students¹⁶ and are an appropriate venue for HIV, STD, and teen pregnancy prevention programs.¹⁷ Many U.S. schools already have healthcare service infrastructure in place and can play an important role in providing adolescents access to sexual health services. A recent census report indicated that 73,697 registered nurses work in schools,¹⁸ and approximately 2,000 school-based health centers (SBHCs) serve at least one grade of adolescents (sixth grade or higher).¹⁹ There is evidence that such resources have some impact on increasing adolescent use of sexual health services. For instance, adolescents in a school with a school-linked clinic and on-campus counselors had a lower pregnancy rate than students in a comparison school.¹⁷ There is also some evidence that a school-based referral program helped school nurses connect students to adolescent-friendly community providers and increased adolescent use of reproductive health services (contraception, STD testing, counseling), especially among sexually active females.²⁰

These resources, however, may be constrained by budgets, local policies on service provision, limited staff, and other issues. A 2008 survey of school nurses found that less than half of schools have a fulltime registered nurse on staff, and most nurses serve multiple schools. In addition, students with exceptional medical needs—whose numbers have been increasing—take up a major proportion of nurses’ time. The average number of total students served per nurse is 1,151.²¹ SBHCs are somewhat limited in number and geographic location, and not all are permitted to provide on-site testing and treatment for STDs (68%) or HIV testing (64%); about one third (60%) are prohibited from providing contraceptive services.¹⁹

One way to help schools meet the physical health needs of students within these constraints is to strengthen schools’ ability to provide services or to connect students to community resources. For these reasons, one of DASH’s key programmatic strategies is to improve schools’ capacity to increase adolescents’ access to key preventive sexual health services via either direct provision of on-site services or referrals to adolescent-friendly community-based health service providers.

Definitions:

1. Key Sexual Health Services (SHS): For the purpose of this FOA, key SHS include anticipatory guidance for prevention, including delaying the onset of sexual activity; promoting HIV and STD testing, counseling, and treatment, and the dual use of condoms and highly effective contraceptives among sexually active adolescents; HIV and STD testing, counseling, and referral; pregnancy testing; and HPV vaccinations.

2. Linkage: For the purpose of this FOA, linkage describes an organizational partnership, whether formal or informal, between schools and adolescent-friendly providers to improve student access to preventive health services.

3. Referral: For the purpose of this FOA, the term “referral” is used to describe a process of assisting students in obtaining preventive health services through a variety of activities, including, but not limited to, connecting students to adolescent-friendly providers on the basis of an identified need.

4. School-Based Health Centers (SBHC): According to 42 USCS § 1397jj [Title 42. The Public Health and Welfare; Chapter 7. Social Security Act; Title XXI. State Children's Health Insurance Program], school-based health center means “a health clinic that -- (i) is located in or near a school facility of a school district or board or of an Indian tribe or tribal organization; (ii) is organized through school, community, and health provider relationships; (iii) is administered by a sponsoring facility; (iv) provides through health professionals primary health services to children in accordance with State and local law, including laws relating to licensure and certification; and (v) satisfies such other requirements as a State may establish for the operation of such a clinic.”

5. School-Linked Health Centers (SLHC): Youth-focused health care programs (e.g., clinics, health service providers) commonly characterized by the following attributes: are located off school grounds; often serve more than one school; have established methods of referral, communication, and follow-up with SBHC partners; often have extended hours beyond the school day; and often provide a broader scope of services than those available through SBHC.²²

6. Sexually Transmitted Disease (STD): A disease transmitted by sexual contact, such as syphilis, gonorrhea, chlamydia, viral hepatitis, genital herpes, and trichomoniasis. Individuals who are infected with STD are at least two to five times as likely as uninfected individuals to acquire HIV infection if they are exposed to the virus through sexual contact.²³

7. Youth-Friendly Services: “Services with policies and attributes that attract young people to them, create a comfortable and appropriate setting, and meet young people’s needs”.²⁴ Youthfriendly services ensure confidentiality, respectful treatment, and delivery of culturally appropriate care in an integrated fashion at no charge or low cost; and are easy for youth to access.

Resources:

• Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm

• CDC Vital Signs: HIV Among Youth in the US http://www.cdc.gov/vitalsigns/HIVAmongYouth/

• Fact Sheet on HIV Testing Among Adolescents: What Schools and Education Agencies Can Do http://www.cdc.gov/healthyyouth/sexualbehaviors/pdf/hivtesting_adolescents.pdf

• STD Treatment Guidelines, 2010, Special Populations (includes screening of adolescents) http://www.cdc.gov/std/treatment/2010/specialpops.htm

• How to Obtain Medicaid Funding for School-Based Services: A Guide for Schools in Systems of Care Communities

http://www.tapartnership.org/docs/obtainingMedicaidFunding.pdf

• CMS Medicaid School-based Administrative Claiming Guide http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Financing-andReimbursement/Downloads/2003_SBS_Admin_Claiming_Guide.pdf

References:

1. CDC. Vital Signs: HIV infection, testing, and risk behaviors among youth – United States. MMWR 2012;61(47):971– 976. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6147a5.htm?s_cid=mm6147a5_w.

2. Weinstock H, Berman S, Cates W Jr. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspectives on Sexual and Reproductive Health 2004;36(1):6–10.

3. Dunne EF, Unger ER, Sternberg M, McQuillan G, Swan DC, Patel SS, et al. Prevalence of HPV infection among females in the United States. Journal of the American Medical Association 2007;297(8):813–819.

4. CDC. Youth risk behavior surveillance—United States, 2011. MMWR 2012;61(SS-4). Available at http://www.cdc.gov/MMWR/PDF/SS/SS6104.PDF

5. U.S. Public Health Service. Clinician’s Handbook of Preventive Services: Put Prevention into Practice. 2nd edition. Alexandria, VA: International Medical Publishing; 1998.

6. Elster AB, Kuznets NJ, editors. AMA Guidelines for Adolescent Preventive Services (GAPS): Recommendations and Rationale. Baltimore: Williams & Wilkins; 1994.

7. Green M, Palfrey JS, editors . Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents.

2nd edition. Arlington, VA: National Center for Education in Maternal and Child Health; 2000.

8. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd edition. Alexandria, VA: International Medical Publishing; 1996.

9. CDC. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR 2006;55(RR-14). Available at http://www.cdc.gov/mmwr/pdf/rr/rr5514.pdf

10. Screening for Gonnorhea, Topic Page. October 2011. U.S. Preventive Services Task Force. Available at http://www.uspreventiveservicestaskforce.org/uspstf/uspsgono.htm.

11. Screening for Chlamydial Infection, Topic Page. June 2007. U.S. Preventive Services Task Force. Available at http://www.uspreventiveservicestaskforce.org/uspstf/uspschlm.htm.

12. CDC. FDA licensure of bivalent human papillomavirus vaccine (HPV2, Cervarix) for use in females and updated HPV vaccination recommendations from the Advisory Committee on Immunization Practices (ACIP). MMWR 2010;59(20):626–629. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5920a4.htm.

13. CDC. Recommendations on the use of quadrivalent human papillomavirus vaccine in males — Advisory Committee on Immunization Practices (ACIP). MMWR 2011;60(50):1705–1708. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6050a3.htm

14. Winer RL, Feng Q, Hughes JP, O’Reilly S, Kiviat NB, Koutsky LA. Risk of female human papillomavirus acquisition associated with first male sex partner. Journal of Infectious Diseases 2008;197:279–282.

15. Block S, Nolan T, Sattler C, Barr E, Giacoletti KED, Colin DM, et al. Comparison of the immunogenicity and reactogenicity of a prophylactic quadrivalent human papillomavirus (types 6, 11, 16, and 18) L1 virus-like particle vaccine in male and female adolescents and young adult women. Pediatrics 2006; 118(5):2135–2145.

16. United States Census Bureau. School Enrollment. U.S. Department of Commerce, Census Bureau Web site. Available at http://www.census.gov/hhes/school/.

17. Zabin LS, Hirsch MB, Smith EA, Streett R, Hardy JB. Evaluation of a pregnancy prevention program for urban teenagers. Family Planning Perspectives 1986;18(3):119–126.

18. U.S. Department of Health and Human Services, Health Resources and Services Administration (2010). The Registered Nurse Population Initial Findings from the 2008 National Sample Survey of Registered Nurses. Available at http://bhpr.hrsa.gov/healthworkforce/rnsurveys/rnsurveyinitial2008.pdf.

19. National Assembly on School-Based Health Care. School-Based Health Centers: National Census School Year 20072008. National Assembly on School-Based Health Care Web site. Available at http://ww2.nasbhc.org/NASBHCCensusReport07-08.pdf.

20. Dittus P, Loosier P, DeRosa C, Ethier K, Jeffries R, Afifi A, et al. The Project Connect health systems intervention:

sexual and reproductive health outcomes for sexually active youth (Paper presented at the March 2011 Society for Adolescent Health and Medicine Annual Meeting, Seattle, WA.)

21. National Association of School Nurses. School Nursing in the United States: Quantitative Study. National Association of School Nurses Web site. Available at http://www.nasn.org/portals/0/2007_Burkhardt_Report.pdf.

22. Fothergill K, Orlick B. The School-Linked Health Center: A Promising Model of Community-Based Care for Adolescents. 1997. Advocates for Youth. Available at http://www.advocatesforyouth.org/index.php?option=com_content&task=view&id=543&Itemid=177.

23. CDC. The role of STD detection and treatment in HIV prevention - CDC Fact Sheet. 2007. Available at http://www.cdc.gov/std/hiv/STDFact-STD-HIV.htm.

24. PATHS: Providing Access to HIV Testing Through Schools: A Resource Guide for Schools. ETR Associates. Scotts Valley, CA. 2011 Available at http://recapp.etr.org/recapp/documents/programs/PATHS.pdf.